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LEANNE GALLEGOS BSN, RNSENIOR CONSULTANTPROGRESSIVE SURGICAL SOLUTIONSA DIVISION OF BSM CONSULTING

ASC SURVEY WATCH 2019

Surveyors

Medicare (CMS) Accreditation

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Medicare’s Top Citations 2018Q0241 Sanitary Environment 27% Infection ControlQ0181 Administration of Drugs 24% Pharmaceutical ServicesQ0242 Infection Control Program 19% Infection ControlQ0162 Form & Content of Record 14% Medical recordsQ0101 Physical Environment 11% EnvironmentQ0104 Safety from Fire 10% EnvironmentQ0141 Organization & Staffing 9% Nursing ServicesQ0240 Infection Control 8% Infection Control Q0261 Admission Assessment 7% Patient Admission, Assessment and DischargeQ0100 Environment 7% Environment

TJC: Most Challenging Standards

IC.02.02.01 The organization reduces the risk of infections associated with medical equipment, devices, and supplies.

LS.03.01.10 Building and fire features designed & maintained to minimize the effects of fire, smoke, and heat.

HR.02.01.03 Grants initial, renewed, or revised clinical privilegesIC.02.01.01 Implements infection prevention & control activities

MM.03.01.01 Safely stores medicationsEC.02.03.05 Maintains fire safety equipment & fire safety building featuresEC.02.02.01 Manages risks related to hazardous materials & wastesEC.02.05.07 Inspects, tests, & maintains emergency power systemsEC.02.05.01 Manages risks associated with it’s utility systemsEC.02.04.03 Inspects, tests, and maintains medical equipment

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AAAHC: Top Trending Deficiencies

1 Quality Improvement activities2 Safe injection practices 3 Credentialing, privileging 4 Documentation management

A Closer Look

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Governance § No documented evidence to show the Governing Body evaluated the effectiveness of the QAPI program or the Infection Control Program.

§ No review and approval of the performance of clinical research activities.

§ No written protocols related to research activities.

Credentialing/Privileging

§ Surgeons were not granted privileges for supervising CRNAs.

§ CRNAs did not request specific privileges for approval.

§ Failed to include peer review results in the physician reappointment process.

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Available on eSupport

eSupport/Operations/Staffing

Personnel Files

§ No evidence of job specific competencies on file for staff.

§ Last competency review of the administrative RN providing patient care documented in 2014.

§ Only one of the two types of competency used for CLIA waived testing on file for nursing personnel.

§ CLIA waived competency training not completed annually.

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Infection Control

§ Staff failed to clean/or disinfect vital sign (temperature, blood pressure cuff and sphygmomanometer) machine in between patient use.

§ Staff did not follow manufacturer’s guidelines for cleaning the ocular lens for the Yag laser.

§ Corrugated boxes noted in the Operating Room and Sprinkler Riser Room/Storage Room.

§ Sink faucets in the hand washing area, nurses station, pre/post admission areas, scrub sinks in the surgical area, and patient’s restroom had aerators and mineral deposits around the spigot.

Infection Control

§ Medication and Patient food refrigerators had heavy accumulation of ice in the freezers.

§ Staff scrubs were on hangers and dragging on the floor.

§ Physicians and nurses didn’t clean rubber septum of med vial.

§ Anesthesia provides noted carrying syringes in front scrub pocket.

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Infection Control

§ Nursing staff failed to perform appropriate hand hygiene during patient care.

§ Disinfectant wipes were not used according to manufacturer’s directions for use. Surface did not remain wet for 2 minutes prior to wiping.

§ The wipe used to clean the glucometer was not registered with the EPA.

§ Purell hand sanitizers expired.§ Head rests on the OR tables had multiple

tears.

Instrument Processing

§ Containers used for transport of dirty instruments from the operating room to the processing area, were not labeled with a bio-hazardous sticker.

§ Sterile processing tech could not state which manufacturer’s guidelines they were following.

§ Observed that there was no documentation of Biological Indicator result.

§ Facility utilized IUSS for a majority of cataract procedures.

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Available on eSupport

eSupport/Operations/Infection Control

Medication Management

§ Medication refrigerator did not have a continuous read thermometer.

§ Look alike sound alike meds (LASA) were not labeled.

§ No policy r/t LASA meds, therefore, a list was not approved by Governing Body.

§ Multi-dose medications not stored away from immediate patient care areas.

§ Anesthesia carts containing controlled substances were unlocked and unattended.

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Medical Records

§ Clinical records did not contain documentation of whether or not the patient had an advance directive.

§ Clinical records did not include reactions to the listed allergies.

§ No physician orders for medications administered to patients.

§ RN did not instill eye drops per physician’s order. Eye drops were administered immediately after the other; however, physician’s orders state to wait 5 minutes.

Medical Records

§ The plan of anesthesia was not documented.

§ Anesthesiologist preoperative assessment did not document heart and lung assessment per organization policy.

§ Though the anesthesiologist documented 'RRR' and 'CTA' on the Heart and Lung pre-sedation assessment, in the pre-op area, no hands on assessment was observed, including use of a stethoscope.

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Medical Records

§ Medication reconciliation was not performed or documented.

§ The discharge diagnosis was not documented by the operating physician.

§ Post-op note was signed by the physician, but not dated and timed.

§ No follow-up care documented on the Post-op phone call sheet.

Medical Records

§ No immediate post op notes documented for pain management procedures.

§ The immediate procedure note and final operative note was not included in clinical records.

§ Clinical records did not contain operative reports.

§ There was no discharge order signed by the physician performing the surgery.

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QAPI § No documentation of external benchmarking.

§ Failed to conduct quality improvement projects.

§ Failed to measure, analyze and track quality indicators, adverse patient events, patient infections/complications.

Available on eSupport

eSupport/Operations/Quality Management

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Available on eSupport

eSupport/Compliance/Survey Watch

Resources§ PSS Client Survey Reports 2018, 2019

§ Most Challenging Standards for AHC (The Joint Commission Ambulatory Buzz) https://www.jointcommission.org/ambulatory_buzz/top_10_most_challenging_standards_for_ahc_and_obs_accredited_organizations/

§ Top Trends in ASC Accreditation Deficiencies (Becker’s ASC Review) https://www.beckersasc.com/asc-accreditation-and-patient-safety/tops-trends-in-asc-accreditation-deficiencies-4-qs-with-aaahc-experts.html

§ Medicare’s Top Citations in 2018- ASCA https://www.ascfocus.org/Go.aspx?c=201903-medicares-top-citations-in-2018

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Join us in Dallas! Feb 6-7, 2020

ASC N U R SELEAD ER SH IP.C OM

The 2019 Webinar Line Up!

DATE 🕒 CE WEBINAR TOPIC SPEAKER

October 25 60 min ✔ Documentation Best Practices Crissy Benze

November 25 20 min Medication Shortages and How to Handle Them Greg Tertes

December 20 60 min ✔ Informed Consent Debra StinchcombWill Miller

www.ProgressiveSurgicalSolutions.com/webinars